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Employment Application

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, handicap, or national origin.

LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES YOU HAVE USED TO IDENTIFY YOURSELF (FOR REFERENCE PURPOSE ONLY)

CURRENT
MAILING
ADDRESS
STREET
CITY
STATE
ZIP
PERMANENT ADDRESS (IF DIFFERENT FROM ABOVE)

TELEPHONE
ALTERNATE TELEPHONE
BEST TIME TO CONTACT YOU
AM PM
HOW WERE YOU REFERRED TO US?

HAVE YOU BEEN EMPLOYED HERE BEFORE?
Yes No   IF yes, give dates From: To:
EVER APPLIED TO THIS COMPANY BEFORE?
Yes No   When? 
ARE YOU LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?
Yes No
HAVE YOU EVER BEEN CONVICTED OF, OR ENTERED A PLEA OF GUILTY OR NO-CONTEST TO, A FELONY?***
Yes No   (EXPLAIN) 
*This information may be considered in hiring or job placement, but will not automatically disqualify you for employment.

POSITION DESIRED:
SALARY DESIRED:
DATE AVAILABLE TO START WORK
EMPLOYMENT INTEREST:
Full-Time  Part-Time
Educational Record
School
Name & Location
Course of Study
Years Completed
Graduate
Certification/Degree
High



YN

Technical



YN

College



YN

College



YN

EXTRACURRICULAR ACTIVITIES IN WHICH YOU PARTICIPATED - PLEASE INDICATE ANY OFFICES HELD***

***Applicant need not disclose any activities which might reveal them as a member of a protected class.
Licenses and/or Certifications
Current number

License Certificate Registration
Occupation

Status of License Expiration Date

State Issued Date Issued

Other Qualifications

Describe any training or qualifications (not previously covered) that might be of interest.

Employment History - List Most Recent First
Company Name
From (mm/yy)
To (mm/yy)
Starting Salary
Job Title
City
State
Ending or Current Salary
Supervisor's Name
Telephone
Reason For Leaving
Brief Job Description
May we contact This Employer?
Yes Immediately
Yes At a Later Date
No, Do Not Contact
Company Name
From (mm/yy)
To (mm/yy)
Starting Salary
Job Title
City
State
Ending or Current Salary
Supervisor's Name
Telephone
Reason For Leaving
Brief Job Description
May we contact This Employer?
Yes Immediately
Yes At a Later Date
No, Do Not Contact
Company Name
From (mm/yy)
To (mm/yy)
Starting Salary
Job Title
City
State
Ending or Current Salary
Supervisor's Name
Telephone
Reason For Leaving
Brief Job Description
May we contact This Employer?
Yes Immediately
Yes At a Later Date
No, Do Not Contact
Company Name
From (mm/yy)
To (mm/yy)
Starting Salary
Job Title
City
State
Ending or Current Salary
Supervisor's Name
Telephone
Reason For Leaving
Brief Job Description
May we contact This Employer?
Yes Immediately
Yes At a Later Date
No, Do Not Contact
References
List 3 Professional References
Name



Relationship/Title



Address



Phone #




Applicants Statement
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false, misleading or omitted information may result in my dismissal. I authorize Lakeview Clinic, Ltd. to conduct an investigation of my previous employment and educational history, I agree to cooperate in the investigation and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the Company, without giving me prior notice of such disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing.

I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies and procedures. The Company retains the right to revise its policies, in whole or in part, at any time.

I certify that I have read, fully understand and accept all terms as stated above.

Applicant's Name
Date


Affirmative Action Questionnaire

In compliance with Local, State, and Federal Affirmative Action and Equal Employment regulations, Lakeview Clinic, Ltd., is responsible for developing a monitoring system to evaluate its selection and hiring practices, measure the effectiveness of its Affirmative Action Plan and produce required reports to various governmental agencies.

In order to comply with these regulations we need to identify certain applicant data. You are not required by law to provide the information requested.

If you elect to provide the information, it will be detached from your application and will not be used to make a decision about employment.

General Information:

Name

Telephone #

Address

Address 2


Male Female American Indian/Alaskan Native
Caucasian
Asian / Pacific Islander
Hispanic
Black
Do Not Wish To Identify

Lakeview Clinic, Ltd. is required to take affirmative action to provide equal employment opportunities to qualified individuals belonging to certain groups listed below. Lakeview Clinic, Ltd. invites all qualified handicapped person, disabled veterans and veterans of the Vietnam Era to self-identify. This information is voluntarily provided and will be kept confidential and used only in accordance with Government Regulation and Lakeview Clinic, Ltd.'s Affirmative Action policy. Refusal to provide this information will not adversely affect consideration for employment. If you believe you are covered by these regulations and wish to receive consideration under them, please complete the following sections as applicable:

Handicapped: Yes No "Handicapped" is defined as a person who:
1. Has physical or mental impairment, which materially limits a major life activity.
2. Has record of such impairment.
3. Is regarded as having such impairment.
List handicapping condition:

Veterans:
Disabled Veteran (Person entitled to VA Disability compensation or discharged from active duty for disability)
Vietnam Era Veterans (served in military service anytime during 8/5/64 - 5/7/75)


Lakeview Clinic, Ltd.'s Affirmative Action Plan is available for viewing in the Administrative Offices of Lakeview Clinic, Ltd.










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